oversight

AIDS Education: Public School Programs Require More Student Information and Teacher Training

Published by the Government Accountability Office on 1990-05-01.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

Nay   1!I!)0
               AIDS EDUCATION
               Public School
               Programs Require
               More Student
               Information and
               Teacher Training
H-23888 1

May 1,lQQO

The Honorable John Glenn
Chairman, Committee on
   Governmental Affairs
IJnited States Senate

Dear Mr. Chairman:

This report responds to your request and subsequent discussions with your staff concerning
certain programs to prevent the spread of the human immunodeficiency virus (HIV), which
causes acquired immunodeficiency syndrome (AIDS). l The programs at issue are managed by
the Centers for Disease Control (CDC),an agency in the Department of Health and Human
Services. As part of our ongoing review of AIDS education and prevention efforts, you asked
us to obtain information on CDC’S AIDS education program aimed at school-aged youth.

We have surveyed the public school districts across the nation regarding their AIDS education
efforts and met with CDCofficials. Our report describes the reported growth of AIDS education
programs and identifies areas needing improvement.

IJnless you publicly announce its contents earlier, we plan no further distribution of this
report until 30 days after its issue date. At that time, we will send copies to the Secretary of
Health and Human Services, the Director of CDC,and other interested parties and will
provide copies to others on request. Please contact me at (202) 275-6195 if you or your staff
have any questions concerning this report. Other major contributors are listed in
appendix VI.

Sincerely yours,




Mark V. Nadel
Associate Director, National and
  Public Health Issues




‘Also at your request in September 1988, we addressed education efforts to reach high-risk persons in AIDS Education: Issues
Affecting Counseling and Testing Programs (GAO/IIRD-89-39, Feb. 3, 1989) and AIDS Education: Staffing and Funding Problems
lmvair Progress (GAOm-89 .- 124 , duly 28, 1989).
                                                                             . .
Ekecutive Summary


             About 20 percent of people with acquired immunodeficiency syndrome
Purpose      (AIDS) are in their 20s. As the human immunodeficiency virus’s (HIV)
             median incubation period is estimated at nearly 10 years, many of these
             people probably were infected with HIV while they were teenagers. AIDS
             cases among individuals in their 20s increased by 41 percent during
             1989, similar to the overall increase in AIDS cases. Without a human
             vaccine or cure available, HIV education programs are critical as the pri-
             mary weapon against the medical and social costs of this potentially cat-
             astrophic health threat. Centers for Disease Control (CDC) awards for
             school-based education began with $7 million in 1987 and expanded to
             $25 million in 1989. Limited information is available about the extent of
             this rapidly growing school-based program.

             The Chairman of the Senate Committee on Governmental Affairs asked
             GAO to assess the progress of school HIV education programs for his
             ongoing review of education efforts led by CDC.


             Many teenagers are engaging in sexual behavior that can transmit HIV.
Background   Some youth also experiment with drugs that cloud their judgment,
             increase sexual activity, and cause addictive cravings-all of which can
             lead to high-risk behaviors.

             HIV  education programs provide information on what AIDS and HIV are,
             how the virus is spread, and what people can do to prevent infection.
             Behavioral skills components, such as how to say no to drugs, are also
             included to teach children how to modify behavior. Training for HIV
             teachers is critical. Not only must they impart correct information on”
             HIV, they also must impel youth to avoid risky behavior. The latter
             requires skills in persuasion, group dynamics, and decision-making.

             cbc, the lead federal agency for HIV prevention, initiated a nationwide
             education program late in 1986. It envisioned a multiyear effort to build
             the nation’s school-based HIV education program aimed at reaching the
             90 percent of children who are in U.S. public schools. As its main func-
             tion, CDC provides funds and technical assistance to state and selected
             local education departments through cooperative agreements. Education
             departments then design and operate their own programs.

             GAO   surveyed by telephone officials from a nationwide sample of school
             districts and the 13 local districts whose direct CDC funding began in
             1987. The purpose was to determine if HIV education was offered and



             Page 2                               GAO/HRD-90-103 AIDS Education in Public Schools




                                           ., :
                           Fkecutive Summawy




                           what teacher training was offered. GAO also reviewed cnc records relat-
                           ing to planning and monitoring data collected by the funded state and
                           local education departments. GAO interviewed CDCofficials and reviewed
                           existing literature.


                           cnc-led nationwide education efforts are not yet commensurate with the
Results in Brief           epidemic’s potential for disaster. Two-thirds of the nation’s public
                           school districts reported providing formalized HIV education for students
                           in the 1988-89 school year. It is not, however, offered at every grade
                           level, especially the upper grades, where the probability of sexual activ-
                           ity is highest. Most cnc-funded education departments do not collect
                           from students the essential planning and monitoring information needed
                           to set program priorities and evaluate success. This is due to a lack of
                           staff and difficulty in obtaining community support to collect sensitive
                           sexual and drug use data. One of five HIV teachers received no training.
                           Although the majority of HIV teachers did receive training, it was often
                           insufficient-too    brief and coverage of important topics was limited.
                           CDCprovides no guidance to districts on the appropriate length of such
                           teacher training.



Principal Findings

HIV Education UsSually     CDC believes it is crucial that students at every grade level receive age-
Required, but Not at All   appropriate HIV education to expand on and reinforce knowledge over
                           the years. But only 6 percent of the school districts required that HIV
Grade Levels               education be provided at every grade level. The most coverage is in the
                           middle grades (7 through 10) and the least in the upper grades, where
                           the probability of sexual activity is highest.

                           School district officials told GAO they were restricted by already
                           crowded curricula (see ch. 2). Most public school districts (66 percent)
                           required that HIV education be provided at some point in grades 7-12
                           during the 1988-89 school year. Of the districts that did not require HIV
                           education, most enrolled fewer than 460 students. CDCofficials should
                           pay particular attention to the needs of these smaller districts for HIV
                           education.




                           Page 3                             GAO/HUD-W&103 AIDS Education in Public Schools
                          Executive Summary




Important Plann ing and   The data collected by state and local education departments on students’
Monitoring Data Are       knowledge, beliefs, and behaviors are inadequate. This hampers efforts
                          to set program priorities, evaluate success, and improve operations,
Inadequate                judging by our review of CDC records and discussions with CDCofficials.
                          Without such information, educators and CDCattempting to assess high-
                          risk behaviors of youth must rely on the results of other surveys, which
                          may not be related to specific student populations. In 1988, CDCpro-
                          vided funds through cooperative agreements, of which one key objective
                          was to gather adequate student data. CDChas developed suggested ques-
                          tions for districts to ask students (see app. III).

                          But most recipients did not collect this essential information, CDCoffi-
                          cials said, for various reasons. Because this was the first program year
                          for many states, some lacked staff to carry out the requirement. In other
                          cases, recipients could not obtain state or local authorization to ask
                          questions about students’ behavior, particularly sexual or drug use
                          behavior (see ch. 2).


Training for SomeHIV      Although education authorities recommend that teachers receive at
Teachers Absent or        least 12 hours of training, one-fifth of HIV teachers received no special-
                          ized training in the subject. Most HIV teachers (83 percent) did receive
Insufficient              training, but it was less than recommended. Of the nation’s districts that
                          offered HIV education, teachers in 67 percent received training of 10
                          hours or less, with a median of only 7 hours. Additionally, in many dis-
                          tricts limited training time was devoted to key topics, such as the impor-
                          tance of using condoms.

                          Most officials of school districts nationwide that offered HIV education
                          expressed a desire to provide more training to their current HIV teachers.
                          Officials stated that the minimal training currently being obtained was
                          related to such problems as not enough in-service days to offer exten-
                          sive HIV training and teachers being reluctant to attend training outside
                          of regular work hours. One local official, citing limited resources, said
                          the district had a choice of reaching all its HIV teachers with a little
                          training or only a few with more in-depth training.

                          In contrast, the 13 school districts directly funded by CDCgenerally
                          trained a higher percentage of teachers, had longer training sessions,
                          and covered key topics more extensively than other districts nation-
                          wide. CDC and state officials attributed this difference to the direct CDC
                          funding and the higher incidence of AIDS in these districts (see ch. 3).



                          Page 4                            GAO/HRD-90-103 AIDS Education in Public Schools
                    Executive fhnmary




                    CDC’SHIV education guidelines recommending that HIV teachers be
                    trained were issued in January 1988. But the agency has not yet set
                    standards for the number of training hours required to effectively teach
                    about HIV or the amount of time to be spent on important topics. While
                    CDC did not disagree that 12 hours may be the minimum necessary,
                    agency officials said they are in the process of researching the extent of
                    training necessary.


                         recommends that the Secretary require the Director of CDCto (1)
Recommendationsto   GAO
                    take a leadership role in developing approaches to extend and reinforce
the Secretary of    HIV-related education for 1 lth- and 12th-grade students, (2) work with
Health and Human    state education agencies to assist smaller school districts in overcoming
                    resource or community barriers that prevent them from offering HIV
Services            education, (3) ensure that state and local grantees collect adequate data
                    from students to evaluate and improve school-based programs, and (4)
                    develop guidelines for the training of HIV educators.


                    GAO discussed the contents of this report with   the CDC Deputy Director
Agency Comments     (HIV), the Deputy Director of CDC’S Center for  Chronic Disease Preven-
                    tion and Health Promotion, and the Director of the Division of Adoles-
                    cent and School Health. They generally agreed with the information
                    presented. The officials stated that HIV education should be locally
                    determined and consistent with parental values. They believe that HIV
                    education has expanded to other school districts since GAO collected its
                    data (summer 1989). CDCofficials stated that data on students’ knowl-
                    edge, beliefs, and behaviors needed improvement. They also said that
                    some of the data available, even if not generalizable, could be useful if
                    employed in an appropriate manner. After only 1 or 2 years of funding,
                    most school districts in the nation have rapidly begun to provide some
                    form of HIV education, although much remains to be accomplished, the
                    officials said (see ch. 4).




                    Page 5                            GAO/HUD-90403 AIDS Education in Public Schools
Contents


Executive Summary                                                                                     2

Chapter 1                                                                                             8
Introduction           Background                                                                    8
                       Objectives, Scope, and Methodology                                           13

Chapter 2                                                                                           16
Student HIV            CDC’s School-Based HIV Education Program
                       Most Districts Required HIV Education in 198889 School
                                                                                                    16
                                                                                                    17
Education                  Year
                       Planning and Monitoring Data Inadequate                                      21
                       Some Sensitive Topics and Behavior Change Skills Not                         23
                           Addressed

Chapter 3                                                                                           26
Teacher HIV Training   One-Fifth of Teachers Not Trained                                            26
                       Length of HIV Teacher Training Often Insufficient                            27
Often Inadequate or    Limited Time Devoted to Important HIV Topics                                 28
Lacking                Most Districts Would Like Additional HIV Teacher                             29
                            Training

Chapter 4
Conclusions,           Conclusions
                       Recommendations to the Secretary of Health and Human
Recommendations,           Services
ad Agency Comments     Agency Comments

Appendixes             Appendix I: Excerpts From CDC’s Guidelines for HIV                           32
                           Education
                       Appendix II: Estimates and Sampling Errors for Selected                      36
                           GAO Interview Responses
                       Appendix III: CDC’s Suggested KBB Questions for                              37
                           Students
                       Appendix IV: Topics Covered During In-Service Training                       43
                           by 13 CDC-Funded Districts
                       Appendix V: Topics Covered During In-Service Training                        44
                           by School Districts Nationwide
                       Appendix VI: Major Contributors to This Report                               46




                       Page 6                          GAO/HRD-flO-103 AIDS Education in Public Schools
          Contents




Tables    Table 2.1: HIV-Related Topics Covered by Sex Education                      24
              Teachers Nationally
          Table 2.2: Condom-Related Topics Covered by Sex                             24
              Education Teachers Nationally         x
          Table 2.3: Prevention Topics Included in Teaching Guides                    25
          Table 3.1: CDC-Funded School Districts Provide Lengthier                    27
              Teacher Training Than Nationwide

Figures   Figure 1.1: Distribution of AIDS Cases Among Adults                         10
               Versus Adolescents by Means of Transmission
               (Through Sept. 1988)
          Figure 2.1: Grade Levels at Which HIV Education Usually                     18
               Is Taught (1988-89)
          Figure 2.2: Grade Levels HIV Education First Introduced                    20
               Into Formal Curricula (1988-89)
          Figure 2.3: Number of Class Periods of HIV Education                       21
               (1988-89)




          Abbreviations

          AIDS       acquired immunodeficiency syndrome
          CDC        Centers for Disease Control
          GAO        General Accounting Office
          HIV        human immunodeficiency virus
          IV         intravenous
          KBB        knowledge, beliefs, and behaviors
          STD        sexually transmitted disease


          Page 7                          GAO/HRDBO-103 AIDS Education in Public Schools
Chapter 1

Introduction


               American youth are not immune to the potentially catastrophic health
               and social costs of acquired immunodeficiency syndrome (AIDS). About
               20 percent of people with AIDS are in their 20s. Former Surgeon General
               Koop told the House Select Committee on Children, Youth, and Families
               in 1987 that “Since the time between infection with the AIDS virus and
               onset of symptoms may be several years, some proportion of those aged
               20-29 who have been diagnosed with AIDS were most likely infected as
               teenagers.” Today, the median incubation period for the human immu-
               nodeficiency virus (HIV) is estimated at nearly 10 years. Of additional
               concern, the number of AIDS cases in the 20- to 29-year-old age group
               increased by 41 percent from January through December 1989, which
               was similar to the overall increase in AIDS cases.

               Scientific progress has created “a dangerous, perhaps even growing,
               complacency toward an epidemic many people want to believe is over,”
               the chair of the National Commission on AIDS warned in 1989. But with
               no human vaccine or cure yet available, AIDS prevention programs are
               the primary weapon against the medical and social costs of this epi-
               demic, Centers for Disease Control (CDC)awards for youth education
               were initiated in 1987 at $7 million and grew to $25 million by 1989.
               Specific information about HIV programs targeted to youth in schools has
               been limited.

               The Chairman of the Senate Committee on Governmental Affairs asked
               us to assess the status of school AIDS education programs as part of his
               ongoing review of education and prevention efforts led by CDC.


                     is the final stage of the disease caused by infection with HIV. Health
Background     AIDS
               experts now realize that HIV infection occurs years before AIDS is mani-
               fest; during this time the virus is infectious to other people. Therefore,
               current emphasis is on education about the dangers of HIV transmission.
               In the remainder of this report, we refer to education related to all
               phases of the disease as HIV education.

               Youth are at risk of HIV infection through sexual and drug use behavior.
               They may be at even higher risk of heterosexual transmission than the
               general population. One study found that many youth lack information
               about how HIV is transmitted and how to avoid it. Yet even those youth
               who did have information did not change their behavior.




               Page 8                             GAO/HRD-90-103 AIDS Education in Public Schools
                       Chapter 1
                       Introduction




The HIV Epidemic and   The next generation of persons with AIDS is becoming infected now, as
Youth                  the Journal of the American Medical Association noted in August 1988.
                       There are currently over 36 million youth aged lo-19 in the United
                       States; this number should increase by 10 percent in the 199Os, with
                       half of the increase coming in minority groups, who are at higher risk.
                       “The potential for this epidemic to spread like wildfire among teenagers
                       is blatantly obvious,” the chairman of a task force on adolescents for the
                       American Academy of Pediatrics states,

                       Several New York state and city studies found that 10 in 1,000 19-year-
                       olds and 1 in 1,000 15year-olds giving birth statewide were infected
                       with HIV. The first large study to determine the rate of HIV infection on
                       college campuses found that about 2 in 1,000 students were infected.’

                       AIDS-infected youth age 12 and over are less likely to have contracted
                       the disease through homosexual behavior or IV drug use than are AIDS-
                       infected individuals generally, data from the Children’s Defense Fund
                       show (see fig. 1.1). But transmission of the virus through heterosexual
                       contact is twice as prevalent among youth. The data are drawn from
                       73,262 total AIDS cases reported through September 1988 (individuals
                       age 12 and over), of whom 865 were youth.




                       ‘President of the American College Health Association.



                       Page 9                                        GAO/HRD-90-103 AIDS Education iu Public Schools
                                         Chapter 1
                                         Introduction




Figure 1.1: Distribution of AIDS Cases
Among Adulfs Versus Adolescents by       70   Porcont of AIDS Caws
Mean8 of Transmission (Through Sept.




                                         30


                                         20


                                         10




                                         AIDS Cane aubgroupa


                                               1        Adults, age 12+
                                                        Adolescents, age 13-21

                                         Source: Children’s Defense Fund; Teens and AIDS: Opportunities   for Prevention, November 1988,
                                         Adolescent Pregnancy Prevention Clearinghouse.




Youthful Sexual Behaviors                Former Surgeon General Koop has said, “Everything that turns up con-
Increase Risk of HIV                     firms heterosexual spread [of AIDS], numerically and geographically.”
                                         Further, heterosexual transmission among inner-city minority youth is a
                                         clear and present danger, said Karen Hein of the Albert Einstein College
                                         of Medicine, who cites an analysis of the most recent data from New
                                         York City. Yet the myth that there is no need to educate heterosexuals
                                         because the disease is not spreading beyond homosexual or drug-using
                                         people persists, the Citizen’s Commission on AIDS says. This belief hin-
                                         ders adequate education efforts.

                                         Many teenagers engage in sexual behaviors, such as unprotected inter-
                                         course or intercourse with two or more partners, that can transmit HIV.
                                         Data show that:




                                         Page 10                                       GAO/HRD-W-103 AIDS Education in Public Schools
chapter 1
Introduction




1. Youth have sex at an early age-the average age of first intercourse
is 16. The Office of Technology Assessment reports that ‘78 percent of
males and 63 percent of females have sex while teenagers.

2. For many adolescents, sexual activity is frequent or often with more
than one partner. Among unmarried females 16 to 19 years old, about
40 percent reported having sex once a week or more, and 51 percent
reported having two or more partners. An official of a national organiza-
tion serving youth said that adolescents interpret a “long-term monoga-
mous relationship” to be one with their current lover that lasts for
several months.

3, Much of teenagers’ sexual intercourse occurs without the protection
of condoms. Although estimates vary, studies we reviewed found that
only about one-quarter of sexually active adolescents used condoms.
Serial monogamy in combination with the reluctance to use condoms
with one’s “monogamous” lover exposes youth to the risks associated
with unprotected intercourse with multiple partners.

Homosexual youth, particularly males, are of special concern as they
have been one of the high-risk groups for HIV transmission in the United
States. As youth, these teens also search for their identity and struggle
to establish satisfying relationships, leading them, in some cases, to
experiment with heterosexual affiliations. This places lesbian youth,
who generally would be in a low-risk category, at heightened risk of
infection. Such exploration also serves as a possible link between homo-
sexual and heterosexual youth in the transmission of HIV,

Thus, many teenagers are at risk of HIV infection through sexual contact.
The gravity of the situation is indicated by the fact that young people
have the highest incidence of sexually transmitted disease (STD) in com-
parison with other age categories. Nearly one-half of the 20 million STD
patients are under age 26. About 2.6 million teenagers contract a sexu-
ally transmitted disease annually. The incidence of STD among minority
youth is generally far higher than among their white counterparts.

Women who become pregnant through unprotected sexual activities
place not only themselves, but also their unborn children, at risk of HIV
infection, as the virus cad be transmitted perinatally. Ten percent of
teenage women become pregnant every year, and 40 percent of U.S.
teens will become pregnant at least once before age 20, the Guttmacher
Institute reports. There are 1 million teen pregnancies each year.



Page 11                           GAO/HRD9@103 AIDS Education in Public Schools
                        Chapter 1
                        Introduction




Drug Use Also Places    Some teenagers are directly at risk of contracting HIV through the shar-
Youth at Risk of HIV    ing of contaminated needles used to inject intravenous (IV) drugs, In
                         1986, 1 percent of high school seniors reported using heroin and 17 per-
                        cent reported using cocaine, which also can be intravenously injected, a
                        National Institute on Drug Abuse report asserts. In addition, about 3 to 4
                        percent of the 15 to 16-year-olds in California, Michigan, and the Dis-
                        trict of Columbia had reported using intravenous drugs, a December
                        1988 CDC study says.

                        In addition, drugs with which some adolescents experiment increase
                        their risk of HIV infection by clouding their judgment, increasing their
                        sexual activity, or causing addictive cravings. All can lead to high-risk
                        sexual behaviors. Some then become involved with other drug users
                        who have contracted HIV. For example, young women who use cocaine
                        or crack may engage in relationships with men who use heroin, an
                        injectable drug. Such youth also may exchange sex for money to finance
                        their substance abuse.


Youth Lack Knowledge,   The National Adolescent Student Health Survey, conducted in 1987 with
Not Changing Behavior   8th and 10th graders, indicated a serious lack of knowledge on AIDS top-
                        ics, such as mode of transmission and means of prevention. In particu-
                        lar, youth had some knowledge about how HIV was transmitted, but did
                        not alter their behavior accordingly. Some changed their behavior
                        groundlessly, for example, not touching doorknobs or sharing popcorn.

                        In a 1986 study of teens in Massachusetts, 96 percent said they knew
                        about AIDS, but only 15 percent had changed their sexual behavior
                        because of concern about it. Of these, only 20 percent took steps such as
                        using condoms or abstaining from sex; 54 percent said they did not
                        worry at all about catching AIDS.

                        Teens experiment freely with drugs and sex for the same reason that
                        they drink or smoke too much and drive too fast. They tend not to
                        believe in their own mortality, states the North American Directory of
                        Programs for Runaways, Homeless Youth and Missing Children. Reach-
                        ing teens with the AIDS message is difficult because most youth do not
                        even think in terms of tomorrow, let alone 5 or 10 years down the road,
                        the latency period for AIDS.

                        Adolescence is characterized by impulsiveness, a desire for immediate
                        gratification, and a tendency to question authority. The latter is espe-
                        cially true when advice from authorities disagrees with the adolescent’s


                        Page 12                           GAO/HRD-90-103 AIDS Education in Public Schools
                            Chapter 1
                            Introduction




                            own limited personal experiences. Other adolescent characteristics, such
                            as their search for an identity and self-esteem with a subsequent need
                            for peer approval, make it difficult for them to resist peer pressure. A
                            lack of social experience, coupled with the dynamics of new sexual rela-
                            tionships, makes it hard for adolescents to justify abstinence from sex or
                            drugs, or the use of condoms.


                            We focused this review on determining the status of the following:
Objectives, Scope,and
Methodology             l Student HIV education required by school districts’ formal curricula for
                          grades 7-12, what grade, course, and for how many class periods it is
                          taught.
                        l Data collection by CDC-funded state and local education departments on
                          students’ HIV knowledge, beliefs, and behaviors for use in planning, mon-
                          itoring, and improving courses.
                        9 In-service training for HIV classroom teachers and for how long topics
                          are covered.

                            We conducted structured telephone interviews of superintendents or
                            their designated staff from 232 randomly selected school districts and
                            the 13 local districts directly funded by CDC in 1987.2 Our findings for
                            the randomly selected districts are representative of the approximately
                            14,200 school districts nationwide in our universe.3 The findings
                            represent the status of required student HIV education and HIV teacher
                            training for all school districts in our universe in the 1988-89 school
                            year. The margin of error for our findings is generally + 6 to ? 10 per-
                            centage points, depending on the item. Sampling errors for specific num-
                            bers are provided in appendix II. Our findings for the 13 CDCdirectly
                            funded districts reflect the status of HIV education in these cities, which
                            were funded because they had high AIDS caseloads.

                            Because the school district generally has considerable control over local
                            HIV education, we discuss the reported activities and requirements of



                            gWe completed interviews in 93 percent of the 232 randomly selected districts and all the 13 other
                            districts. Although we did not sample on the basis of student population, we estimate that the
                            responding districts accounted for 98 percent of public school students in our universe.

                            “We used the 1987-88 public education agency universe of the Department of Education’s common
                            core of data. This is derived from a survey that includes the approximately 16,600 school districts in
                            the nation in 1987-88. The universe for our survey excluded local school districts where the highest
                            grade was less than 7, nonlocal school districts (such as supervisory/regional districts and state-
                            operated agencies), and 49 superintendent offices in California that were designated as local districts
                            but had no student counts. This left about 14,200 school districts from which we sampled.



                            Page 13                                         GAO/HRD-90-103 AID!4 Education in Public Schoola
Chapter 1
IntXOdUCtlOn




school districts. Our estimates of the extent of HIV education are stated
in terms of the frequency with which school districts reported various
HIV education activities. They do not include estimates of the number of
students receiving HIV education. Student estimates would have required
data collection at the school level, which was beyond the scope of our
study.

Our information on student HIV education reflects what school district
officials reported was required by school districts’ formal curricula. We
did not talk to teachers or visit classrooms to see if HIV teachers were
actually adhering to school districts’ curricula requirements, although
we did visit one location before our survey. Nor did we collect informa-
tion about HIV education occurring informally or as part of elective
courses. In addition to reviewing the literature related to AIDS education,
we drew on two studies to help assess what students were taught in the
classroom. (See p. 23.)

The information we present on in-service teacher training relates only to
the training that school districts reported was received by classroom
teachers who teach about HIV. Also, this information relates only to dis-
tricts that required HIV education.

We conducted our work at CDCheadquarters in Atlanta between May
and December 1989. Telephone interviews were done between May 31
and August 18, 1989. Additionally, we interviewed CDC officials respon-
sible for managing these HIV activities and reviewed associated financial
records, cooperative agreement documents, and other CDCrecords. We
discussed the results of our school district interviews with officials from
CDC, six states that had the most districts providing HIV education in our
sample, and three local education departments on the east and west
coasts to obtain their reactions. Their comments were incorporated
where appropriate.

Our work was done in accordance with generally accepted government
auditing standards. At the request of the Committee, we obtained oral
rather than written agency comments on a draft of this report.




Page 14                           GAO/HRD-90.103 AIDS Education in PubIlc Schools
                                                                               ..
Chapter 2

Student HIV Education


                             Nationwide, the majority of school districts had incorporated some form
                             of HIV education into their curriculum in the 1988-89 school year. While
                             nearly all large schools offered such training, a disturbing number of
                             smaller school districts (fewer than 450 students) had not required HIV
                             education for their students. Even schools that offered HIV education
                             programs typically did not require them at all grade levels. Only 5 per-
                             cent of school districts nationwide offered HIV education at each grade
                             level in the 1988-89 school year. HIV education often was not provided at
                             the highest grades, where the probability of high-risk behaviors by
                             youth increases.

                             The Centers for Disease Control has recommended that HIV education be
                             provided at each grade level. CDC believes schools should present age-
                             appropriate HIV information that is expanded upon and reinforced as the
                             students pass from one grade to another.


                             CDCis the lead federal agency for HIV prevention programs. Its Division
CDC’sSchool-Based            of Adolescent and School Health, in the Center for Chronic Disease Pre-
HIV Education                vention and Health Promotion, has responsibility for youth education.
Program                      CDC’Snational education program primarily targets students enrolled in
                             public schools because these schools can reach about 90 percent of the
                             young people in kindergarten through 12th grade. CDCdescribes this as a
                             multiyear effort to build the nation’s school-based HIV education pro-
                             gram. CDC encourages state and local education departments to

                         .   develop curricula and necessary support materials (such as texts,
                             videos, and workbooks);
                             train HIV education teachers;
                             educate parents to support HIV education; and
                             monitor the programs by collecting student information.


CDC Funding Since 1987       Since it began efforts toward HIV education in schools in late 1986, CDC
                             has funded programs principally through cooperative agreements with
                             state and local education departments. In September 1987, CDC awarded
                             $5.4 million to 14 state and 13 local education departments, including
                             the District of Columbia. These 27 awards, ranging from $119,500 to
                             $342,607, involved education departments that served areas with a high
                             incidence of AIDS cases.




                             Page 15                          GAO/HRD90-103 AIDS Education in Public Schools
                           Chapter 2
                           Student HIV Education




                           Also in 1987, cnc awarded $1.8 million to 15 national organizations,
                           such as the Council of Chief State School Officers and the National Asso-
                           ciation of State Boards of Education. These organizations were to use
                           the funds, ranging from $92,919 to $302,000, to help increase the num-
                           ber of schools and other organizations providing HIV education to youth.

                           In August and September 1988, CDC extended funding to a total of 53
                           state and territorial and 17 local education departments. These 70 agree-
                           ments totaled $16.7 million, ranging from $81,182 to $441,267. Simi-
                           larly, CDC awarded $3.8 million to 19 national organizations in 1988. In
                           1989, CDC awarded a total of $25 million to all these organizations.

                           Generally, state and local education departments are responsible for
                           managing their cooperative agreements. CDCprovides general guidance
                           and oversight (see app. I for cm’s guidelines). This cooperative effort
                           stresses the importance of providing immediate education about high-
                           risk behaviors to students. Specific education department activities
                           include developing curricula and materials, training teachers, educating
                           parents, and completing surveys of students’ HIV knowledge, beliefs, and
                           behaviors.


State Involvement in HIV   States have been addressing HIV education issues, as shown by a Decem-
Education                  ber 1988 survey conducted by the Council of Chief State School Officers.
                           The council canvassed all 50 states, the District of Columbia, Puerto
                           Rico, the Virgin Islands, and American Samoa. For these 54 jurisdictions,
                           the council reported: (1) 41 had either a state law or state policy con-
                           cerning HIV education in schools; (2) 41 had a curriculum or a curriculum
                           guide for HIV education, of which 32 were advisory and 9 mandatory;
                           and (3) 41 provided teacher in-service training programs for HIV educa-
                           tion. Only two states said they had not addressed any of the above three
                           categories.

                           That HIV education was required in 28 states and the District of Colum-
                           bia was reported in another survey covering 55 states and territories. It
                           was conducted by the National Association of State Boards of Education
                           in May 1989.




                           Page 16                           GAO/HRD-90-103 AIDS Education in Public Schools
                            Chapter 2
                            Student HIV Education




                            Sixty-six percent of school districts nationwide reported to us that they
Most Districts              required students to receive HIV education as part of their formal curric-
Required HIV                ula in the 1988-89 school year. Of the remaining districts, 27 percent did
Education in 1988-89        not require HIV education, and 7 percent could not be contacted or
                            refused to participate in our survey. Most districts that did not require
School Year                 HIV education had fewer than 460 students; very few had 2,500 or more
                            students. CDC should pay particular attention to these smaller districts to
                            determine their needs in initiating HIV education. The 13 directly CDC-
                            funded school districts all required students to receive HIV education, as
                            their cooperative agreement funding was earmarked to help provide
                            such education.

                            Reasons why school districts required   HIV   education include the
                            following:

                        9 State mandates requiring local districts to teach HIV education and dis-
                          tricts’ initiatives to respond to the HIV epidemic.
                        l The national HIV education program and media attention about HIV.

                            As to why some districts did not require   HIV   education, the following
                            reasons were offered:

                        l   Conservative community values, fear of community reaction, or low
                            incidence of HIV infection locally.
                        l   Insufficient school time to give students the necessary hours of instruc-
                            tion as well as parental reluctance for schools to teach about “safe sex.”

                            Some districts not requiring HIV education indicated that they planned to
                            implement such programs soon or were in the process of developing HIV
                            teaching guides. Also, some districts provided informal HIV education
                            either during a school assembly or at the initiative of individual teach-
                            ers, they said.


HIV Education Not           Very few school districts required HIV education in each grade, our sur-
Provided at All Grade       vey of districts with grades 7-12 showed. Only 5 percent of districts
                            with grade levels 7 through 12 nationwide, and 1 of the 13 high caseload
Levels                      districts directly funded by CDC, required such education at each level. It
                            is crucial that sufficient classroom time be provided at each grade level,
                            CDCguidelines advise. This helps assure that students acquire essential
                            age-appropriate knowledge about HIV and have the information
                            expanded and reinforced each year. CDC and almost all state officials



                            Page 17                           GAO/HRD-90-103 AIDS Education in Public Schools
                                        Chapter 2
                                        Student HIV Education




                                        said already crowded curricula prevented districts from requiring                              HIV
                                        education at all grade levels.

                                        Most school districts nationwide and the cnc-funded districts required
                                        that students receive HIV education at some time in the 7th through 10th
                                        grades. About three-quarters of districts nationwide required students
                                        to receive HIV education in the 7th grade, while few offer it at upper
                                        grade levels (see fig. 2.1).


Figure 2.1: Grade Level8 at Which HIV
Education Usually Is Taught (1988-89)
                                        loo   Pemmtago of school Dktrlcts

                                         so

                                         so

                                         70

                                         60

                                         60

                                         40

                                         so

                                        20

                                        10
                                          0




                                          School ando Lovola

                                              I        CDC-funded
                                                              Diitricts
                                                       Nationwkle Districts




                                        Note: Percentages   total to more than 100 because school districts may require HIV education in more
                                        than one grade.


                                        Most districts nationwide (79 percent) and most of the directly funded
                                        districts (69 percent) required HIV education in health classes, as recom-
                                        mended by enc. Health usually is taught in grades 7 through 10, CDC
                                        officials say. Our data show a drop in HIV education in grades 11 and 12.


                                        Page 18                                         GAO/HRD-90-103 AIDS Education in Public Schools
                           Chapter 2
                           Student HIV Education




                           Even if health is not offered in these grades, HIV education should be
                           continued in some format for older teens, in accordance with CDCrecom-
                           mendations. The increasing likelihood of the onset of sexual activity and
                           the need for reinforcement of the AIDS message offer compelling argu-
                           ments for doing so.


HIV Education Introduced   Most districts reported that they had begun HIV education in formal cur-
in Primary Grades          ricula before the seventh grade- over half of the nationwide and CDC-
                           funded districts that required HIV education had introduced it by the
                           fifth grade (see fig. 2.2). CDC officials recommend that age-appropriate
                           HIV education be provided at each grade level. If this recommendation
                           were strictly followed, then HIV education should be available in first
                           grade or kindergarten. However, given the early introduction of train-
                           ing, most students received HIV information before the average onset of
                           sexual or IV drug use behavior.




                           Page 19                          GAO/HRDDO-103 AIDS Education in Public Schools
                                         Chapter 2
                                         Student HIV Education




Figure 2.2: Grade Levels HIV Education
First Introduced Into Formal Curricula
(1988-89)                                50   Porcantaga of Sofmcl Dlstrlctm

                                         45

                                         40

                                         35

                                         30

                                         25

                                         20

                                         16

                                         10

                                          5

                                         0

                                              Qmdoa K-l             Grader 2-2           Gmdw 4-5               Gmdos 6-7         Gmdos 7-12
                                              School Gmdo Lwols


                                              I        CDC-funded Districts
                                                       Nationwide Districts



                                         Note: Sampling errors for these percentages   are 7 percentage   points or less.




Time Devoted to HIV                      Nationally, from 1 to 40 class periods were required by HIV curricula
                                         during the academic year, the school districts reported. A class period
Education Varied                         usually lasts about 50 minutes. Nationwide districts and the 13 CDC-
                                         funded districts required students to receive a median of five class peri-
                                         ods of HIV education. Twenty percent of districts nationwide reported
                                         that 10 or more class periods were required, and 25 percent reported
                                         that 3 periods or fewer were required (see fig. 2.3).




                                         Page 20                                         GAO/~-DO-103          AIDS Education in Public Schools
                                         Chapter 2
                                         Student HIV Education




Flgure 2.3: Number of Class Periods of
HIV Education (1988-89)
                                         55    Porcmtago cf Schccl Districts




                                         Number of Claw Periods

                                               I       CDC-funded   Di8tficts


                                                       Nationwide Dietkts




                                         By the end of the 1988-89 school year, most of the 70 state or local edu-
Planning and                             cation agencies receiving CDC grants had not collected essential planning
Monitoring Data                          and monitoring data. Of the 70 grantees, 14 did not even conduct the
Inadequate                               necessary surveys on students’ HIV knowledge, beliefs, and behaviors
                                         (Km), and 3 departments had not provided necessary data to CDCto
                                         evaluate sampling results. Forty-five conducted surveys that did not
                                         meet essential standards-they    were not generalizable and/or did not
                                         contain questions relating to students’ behaviors. Only eight collected
                                         adequate data. Of the 56 departments that did surveys, 27 obtained sex
                                         and drug behavior information, but only 8 obtained results that met
                                         both essential standards. The 70 HIV education cooperative agreements
                                         with state and local education departments that CDC funded in 1988
                                         included a provision to gather this planning and monitoring information.

                                         KBR  data are critical to managing, evaluating, and improving state and
                                         local education department HIV education programs. Using baseline KBB


                                         Page 21                                GAO/HRD-90-103 AIDS Education in Public Schools
Chapter 2
Student HIV Education




survey data, an education department can identify students’ knowledge
about HIV and the extent to which behaviors that spread HIV are prac-
ticed. This information then can be used to establish educational priori-
ties and set objectives for changing attitudes and reducing risky
behaviors. Follow-up KBB surveys can provide a basis for measuring pro-
gram impact and evaluating results. Without such information, CDC and
educators must rely on proxy information on the general trends of sex-
ual and drug behavior reported by other surveyors, which may not be
related to their specific population of youth.

CDC   identified two essential standards for effective    KBB   surveys:

 1. Results should be generalizable to the student population. Such
results provide an accurate picture of the population and can be used to
make decisions about the entire HIV program. On various occasions, such
as CDC’SNovember 1988 School Health Education Workshop, CIX noted
the importance of obtaining such statistically useful survey information.

2. Questions about students’ sex and drug behavior should be included
to provide essential information on the extent to which students engage
in risky behaviors that spread HIV. Because the basic purpose of HIV edu-
cation is to eliminate such behavior, CDCviews collection of information
about students’ sex and drug practices as essential to setting program
priorities and monitoring results. CDC has developed a questionnaire that
school districts can use to assess students’ KBBS (see app. III).

In our opinion, the KBB data collected are insufficient because the data
are often not generalizable and because of the limited extent of behav-
ioral information. CDC officials stated that KBB data needed improve-
ment, but that some of the data could be useful, although they did not
meet essential standards. They stated that some education agencies (1)
lacked available staff to collect them because this was the first program
year for many states and/or (2) had difficulty obtaining authorization to
gather certain sensitive information regarding students’ sexual or IV
drug behavior. Among the obstacles to obtaining such data was the per-
ceived community concerns about gathering data on students’ sexual or
IV drug behavior.

Much more remains to be learned about how to motivate long-term
changes in the sexual and drug-using behaviors that spread HIV, as we




Page 22                             GAO/HRD-30-103 AIDS Education in Public Schools
                               Chapter 2
                               Student HIV Education




                               testified in June 1988.1 Neither public organizations nor private founda-
                               tions providing HIV education have done much to ascertain the effects of
                               their programs, recent research shows. Faced with methodological diffi-
                               culties, limited resources, and the urgency of controlling the epidemic,
                               early education programs skimped on evaluation. As a result, informa-
                               tion about the effectiveness of public and private programs has accumu-
                               lated slowly. But tight budgets and the urgency of slowing the spread of
                               HIV among youth only heighten the importance of understanding the
                               effectiveness of education programs.

                               The federal government should take the lead, we testified, in conducting
                               rudimentary studies of what does and does not work in HIV education,
                               Although school health education is an old field, there has been little
                               research on how to modify it for HIV education. The particular challenge
                               is not solely to impart information about the epidemic to youth but to
                               modify behaviors that place them at risk.

                               In 1988, CDCcontracted with IOX Assessment Associates to conduct a
                               $3.2 million, S-year study of what educational approaches work best
                               with youth in modifying their high-risk behaviors. While awaiting its
                               completion, valuable KBB data should be collected and used to plan and
                               modify programs.


                     Two other studies provide some insights on what students have been
SomeSensitive Topics taught  about HIV,
and Bhavior Change
Skills Not Addressed veyed
                     1. More than 90 percent of public school sex education teachers sur-
                            by the Alan Guttmacher Institute2 reported that they covered
                               selected HIV-related topics. For example, 96 percent reported explaining




                               ‘Issues Concerning CDC’s AIDS Education Programs (GAO/T-HRD-88-18, June 8,198s).

                               “d. D. Forrest and J. Silverman. “What Public School Teachers Teach About Preventing Pregnancy,
                               AIDS and Sexually Transmitted Diseases,” Family Planning Perspectives, Vol. 21, No. 2, Mar./Apr.
                               1989.



                               Page 23                                      GAO/HRD-90-103 AIDS Education in Public Schools
                                        Chapter 2
                                        Student HIV Education




                                        how HIV is transmitted (see table 2.1). However, some of the more sensi-
                                        tive topics, such as homosexuality or “safer sex” practices, were cov-
                                        ered less frequently. The nationwide survey covered public school sex
                                        education teachers in grades 7-12.3

Table 2.1: HIV-Related Topic5 Covered
by Sex Education Teachers Nationally    Numbers in percent
                                        HIV-related tot&s covered                                                     Covered by teachers
                                        How AIDS is transmitted
                                        _-.---__--___.                                                                                       96
                                        Effects of the disease                                                                               94
                                        Svmbtoms of the disease
                                        -I   1
                                                                                                                                             91
                                        Condoms
                                        -__         as prevention                                                                            91
                                        Sexual decision-making                                                                               90
                                        Abstinence from intercourse                                                                          89
                                        lmbortance of notifvina oartners if infected                                                         86
                                        Sexual monooamy as prevention                                                                        85
                                        Confidentiality of medical treatment                                                                 77
                                        Homosexuality                                                                                        69
                                        Soecific sources of helb for students                                                                6%
                                        “Safer sex” oractices                                                                                64


                                        Many teachers responding provided information about the condom and
                                        how to use it, according to the survey, as table 2.2 indicates.

Table 2.2: Condom-Related Topics
Covered by Sex Education Teachers       Numbers in percent
Nationally                              Condom-related tooics covered                                                   Covered by teacher
                                        How to use a condom                                                                                  77
                                        Teach that condoms should be put on before any vaginal
                                          contact by the penis                                                                               68
                                        Encourage condom use for prevention of HIV and other
                                          sexually transmitted diseases                                                                      53
                                        Address such concerns as reduced sexual pleasure and lack
                                          of soontaneitv                                                                                     46
                                        Teach that condoms should alwavs be used with spermicides                                            45



                                        ‘$Ofthe 9,800 teachers surveyed, 4,241 responded, yielding a response rate of about 45 percent. The
                                        response rate differed by teacher specialty. It was highest among nurses. Respondents were similar to
                                        nonrespondents in metropolitan status, although teachers from schools with 601-1,000 students were
                                        slightly more likely than those from schools with larger or smaller enrollments to respond to the
                                        survey. Teachers from the North Central region of the country had a slightly higher response rate,
                                        and those from the South had a slightly lower response rate than those from other regions. The
                                        authors note that the size of the school and region of the country were not significantly related to the
                                        responses on a number of variables investigated, suggesting little bias by these factors, other than
                                        that by differences by specialty.



                                        Page 24                                         GAO/HRDQO-103 AIDS Education in Public Schools
                                           Chapter 2
                                           Student HIV Education




                                           2. Some important prevention topics, such as proper use of condoms and
                                           peer resistance skills, were not included in many of the 43 secondary
                                           school HIV teaching guides reviewed by CDC in an unpublished study (see
                                           table 2.3), although CDC feels that the data should be further analyzed.
                                           The guides were obtained from CDC’S AIDS School Health Education data
                                           base. CDC officials noted that the federal HIV education role does not
                                           mandate a specific school curriculum.

Table 2.3: Prevention Topica Included in
Teaching Guides                            Numbers       in percent
                                           _-.- .-.. --_-__-.---.-..-~~..-
                                                                                                                          Covered by te;;xz;i
                                           HIV prevention
                                           ----    ___-~-- topic             ___.       --_                                            ._____
                                           Personal responsibility
                                           Peer resistance and refusal skills                                                          --        37
                                           Enhancement of _self-esteem
                                                            - .._ .._-____-..-__                                                                 44
                                           Modify own behavior                                                                                   79
                                           Abstinence                                               .                                       --
                                           Sex                                                                                                   93
                                           IV drugs                          -.______                          -___                              91
                                           Monogamy
                                           --.-_-_I___..~_____-.-.--.~--.                                         ______--__---
                                           Mutually
                                           --..        faithful with uninfected I.-.
                                                  -.-...__-~-                    partner -.--                                                    47
                                           Condoms
                                           Mentioned                                                                                             93
                                           Reduce risk of exposure to HIV                                                                        79
                                           Additional protection if used together_______-
                                                                                   with spermicide                                     -___      42
                                           Used properly from start to finish with each
                                                                                      ___-sexual act                                             37
                                           Instruction or demo on use                                                                            16
                                           Drugs                                                                                        I_-
                                           Avoid IV use                                                                                           91
                                           Do not share needles or syringes                      ..---                            .-        _-..- 91
                                           Cleaning of works
                                                          --_-. .__--..                                                                           12
                                                                          _____
                                           Seek treatment if addicted                                                                             23




                                           Page 25                                              GAO/HRD-90-103 AIDS Education in Public Schools
TeacherHIV Training Often Inadequate
or Lacking

                        About one out of five HIV teachers in school districts we surveyed had
                        received no training in the subject. Even though most HIV teachers were
                        trained, both the length of this HIV training and the coverage of impor-
                        tant topics often were insufficient. Most of the officials of the districts
                        we surveyed indicated an interest in providing HIV teachers with addi-
                        tional training.

                        Teacher training is a critical component of effective school-based HIV
                        education. In June 1988, the Presidential Commission on the HIV Epi-
                        demic recommended that HIV teachers receive extensive in-service train-
                        ing before they begin instruction. In addition, CDC recommended in
                        January 1988 that HIV teachers should receive specific training as soon
                        as possible (see app. I).’


                        Our survey showed that about one out of every five HIV teachers nation-
One-Fifth of Teachers   wide had not been trained by the end of the 1988-89 school year. Twelve
Not Trained             percent of the school districts nationwide that required student HIV edu-
                        cation provided no teacher training. In about two-fifths of the districts
                        not providing training, officials said teachers do not need HIV training,
                        and the remaining three-fifths cited various barriers to training. These
                        included lack of in-service training days and lack of money to pay for
                        substitute teachers to relieve HIV teachers for training.

                        In-service HIV teacher training was available and utilized by the majority
                        of teachers in our nationwide survey.2 Specifically, 83 percent of HIV
                        teachers in the nation’s school districts actually received the training.
                        All 13 CDc-funded school districts provided HIV teacher training; 91 per-
                        cent of the HIV teachers in these districts received HIV training.

                        Several reasons for the reported teacher training coverage were given
                        by state and CDC officials. Two state officials said that school districts
                        understand that teachers need to receive HIV training. State mandates,
                        HIV teachers requesting training, and 0~‘s emphasis on training were
                        listed by other state officials as additional reasons. The extensive pub-
                        licity concerning HIV and the ready availability of HIV teaching materials
                        helped boost the number of teachers trained, CDC officials added.



                        ‘CDC, Guidelines for Effective School Health Education to Prevent the Spread of AIDS, Jan. 1988.

                        “Some schools require in-service training to be offered to teachers during duty hours or compensate
                        teachers for the time necessary to complete such training.



                        Page 26                                       GAO/HRD-90403 AIDS Education in Public Schoola
                                          Chapter 3
                                          Teacher HIV Training Often Inadequate
                                          or IALckhg




                                          While HIV teachers in school districts that required HIV education do
Length of HIV Teacher                     receive HIV education training, it generally is not as extensive as educa-
Training Often                            tion experts recommend or school districts want. Officials of state and
Insufficient                              local education departments and national education organizations
                                          believe that teachers should receive a minimum of 12 hours of HIV
                                          instruction. This provides basic information about HIV, they contend,
                                          and helps ensure comfort in discussing topics of human sexuality. More
                                          training time is necessary for teachers who lack a background in health
                                          education.

                                          Generally, HIV teachers received less than 12 hours of training, school
                                          district officials nationwide told us (see table 3.1). In 67 percent of
                                          school districts nationally, HIV teachers received training of 10 hours or
                                          less; in 32 percent of districts, 4 hours or less.

                                          HIV classroom teachers in the 13 cut-funded districts generally received
                                          more in-service training than those nationwide-a       median of 12 versus
                                          7 hours. However, HIV teachers in almost one-half of the cut-funded dis-
                                          tricts received training that lasted 10 hours or less.

Table 3.1: CDC-Funded School Districts
Provide Lengthier leacher Training Than                                                               Hours of training
Nationwide                                                                                  Lowest                        Highest
                                          Tvoe of school district                           auarter          Median       auarter
                                          13 CDC-funded districts                                  8               12          16
                                          Other school districts nationwide                        4                7          12


                                          CDC has performed no systematic classroom observations to determine
                                          the nature of HIV education provided nationally. We visited one location
                                          before our survey and observed a range of teacher quality in terms of
                                          the information presented, teaching style, and student reactions.

                                          CDC  issued guidelines in January 1988 recommending that HIV teachers
                                          be trained as soon as possible. But it has not yet developed official or
                                          even preliminary standards for the number of training hours required
                                          by teachers to effectively instruct an HIV course. While CDCofficials did
                                          not disagree with the 12-hour minimum, they contend that sufficient
                                          evidence on the optimal number of hours for HIV teacher training is not
                                          available to support a specific level of training. CDCis concerned that
                                          recommending a minimum amount of time for teacher training may be
                                          undesirable, as it may mistakenly be used as a standard. However, in
                                          light of the seriousness of the HIV epidemic, preliminary guidelines that



                                          Page 27                                 GAO/HRD-90-103 AIDS Education in Public Schools
                       Chapter 3
                       Teacher HIV Training Often Inadequate
                       or Lacking




                       are updated as additional research data are available would be appro-
                       priate. For instance, guidance on the amount of time to be spent on indi-
                       vidual topics to provide meaningful instruction would be useful to
                       school districts, even if a total time for the entire HIV teacher training
                       course is not provided. Such guidelines on content and coverage would
                       be a first step in ensuring the quality of the HIV training.

                       Limited resources, such as funds for substitute teachers while HIV teach-
                       ers are in training, prevented districts from providing more training,
                       state and local officials said. Among their responses:

                       The choice was between reaching all HIV teachers with a little training or
                       only a few with more in-depth training.
                       School administrators may not understand that training teachers to deal
                       with sensitive HIV subjects requires more training time.
                       Teachers in the 13 CDC-funded districts generally received longer train-
                       ing, because of the direct CM=funding available and/or because the
                       higher incidence of HIV in their communities served as an impetus.

                       With respect to the latter, if a higher AIDS caseload has been an impetus
                       for these districts, other districts should not wait for a similar problem
                       to provide their motivation for pursuing HIV education, The chief benefit
                       of HIV education is to prevent infection from occurring.


                       Limited time was devoted to some key topics in teachers’ HIV training,
Limited Time Devoted   perhaps in part due to the insufficient length of in-service training. For
to Important HIV       half or more of the nation’s school districts, training covered 5 of 14 key
Topics                 topics for 15 minutes or less, which educators contend is an insufficient
                       amount of time. These topics tended to cover sensitive subjects, such as
                       the importance of using condoms and the dangers of unprotected homo-
                       sexual intercourse and multiple sex partners. (See app. V for a list of the
                       key topics with their coverage.)

                       Conversely, in the 13 CDC-funded districts, the 14 key teacher training
                       topics almost always are discussed for more than 15 minutes, officials
                       reported. Most of the districts addressed sensitive topics for more than
                       15 minutes. Topics included the importance of using condoms and the
                       risks of unprotected homosexual intercourse. (See app. IV for a list of the
                       key topics with their coverage.)

                       Teacher training should cover topics and approaches having the great-
                       est potential for changing student behavior that could lead not only to


                       Page 28                                 GAO/IIRD-90-103 AIDS Education ln Public Schools
                           Chapter 3
                           Teacher HIV Training Often Inadequate
                           or Lacking




                           AIDS, but also to teen pregnancies and drug abuse problems, CDC guide-
                           lines say. Among these are modes of HIV transmission and behaviors that
                           spread HIV; ways to discuss sensitive topics, such as the use of condoms
                           and homosexual behavior; and ways to help youth resist persuasion,
                           gain decision-making skills, and build self-esteem so they can resist risky
                           behaviors. These topics should be covered for a sufficient amount of
                           time-more than 15 minutes-to allow teachers to gain expertise, edu-
                           cators feel.

                           But teacher training for some controversial or sensitive HIV topics was
                           limited, state and local officials noted, because school staff or individu-
                           als in the community were uncomfortable. With limited training time
                           available to start with, one state official said, topics that are too sensi-
                           tive for teachers or the community are just not substantively addressed.


                           More in-service training is needed, school district officials in 54 percent
Most Districts Would       of districts asserted, and 25 percent said more HIV teachers are needed.
Like Additional HIV        School district officials nationwide listed several problems that inhibit
Teacher Training           their ability to give teachers additional training or train more teachers.
                           Among these problems are the following:

                       l Too few in-service days available to do extensive training.
                       . Teachers’ reluctance to attend training held outside of regular contract
                         or working hours.
                       . Not enough money to pay for substitute teachers.
                       . Too few substitute teachers to release HIV classroom teachers for
                         training.

                           In 12 of the 13 CDC-funded districts, officials want to provide more HIV
                           training to teachers. In 7 of the 13 districts, officials said the number of
                           teachers t,rained is fewer than needed. Officials listed barriers similar to
                           districts nationwide, such as too few in-service days for extensive train-
                           ing, too little money to pay for substitute teachers, and too few substi-
                           tute teachers to release HIV classroom teachers for training.




                           Page 29                                 GAO/HRIMO-103 AIDS Education in Public Schools
Chapter 4

Conclusions,Recommendations,and
Agency Comments

                    Two-thirds of the nation’s public school districts reported IIIV education
Conclusions         programs in progress in grades 7-12 for the 198889 school year. Those
                    not offering HIV education tended to be the smallest school districts.
                    Additional focus on these districts is needed to ascertain their needs in
                    initiating HIV education. But only 5 percent of school districts nation-
                    wide required HIV education at every grade level, as CDCrecommends.
                    HIV education drops off noticeably in the 1 lth and 12th grades, yet this
                    is when students become more sexually active. Moreover, important
                    data on students’ knowledge, beliefs, and behaviors needed to plan and
                    monitor HIV programs either have not been collected or are inadequate to
                    set educational priorities, evaluate success, and improve HIV programs.

                    The majority of teachers in school districts nationwide that required HIV
                    education have received in-service training on how to teach about AIDS.
                    Such training, however, is not as extensive as the districts prefer or
                    authorities recommend. One out of every five HIV instructors has
                    received no training.

                    Judging by available statistics, youth are at risk of HIV infection through
                    various sexual and drug use behaviors. They are at higher risk than
                    adults through heterosexual exploration. AIDS education programs are
                    the primary means to prevent HIV infection in youth. The effort to edu-
                    cate youth about AIDS began only after several years of the epidemic.
                    Although education is increasing in scope and sophistication, it is not yet
                    commensurate with the threat posed and the call by the Surgeon Gen-
                    eral in 1986 for immediate action.


                    GAO recommends that the Secretary require the Director of CDC to (1)
Recommendationsto   take a leadership role in developing approaches to extend and reinforce
the Secretary of    HIV-related education for 1 lth- and 12th-grade students, (2) work with
Health and Human    state education agencies to help smaller school districts overcome
                    resource or community barriers preventing them from offering HIV edu-
Services            cation, (3) ensure that state and local grantees collect adequate KBB data
                    from students to evaluate and improve school-based programs, and (4)
                    develop guidelines for the training of teachers who instruct the HIV edu-
                    cation courses.


                    We discussed the contents of this report with the CDCDeputy Director
Agency Comments
         *          (HIV), the Deputy Director of CDC'S Center for Chronic Disease Preven-
                    tion and Health Promotion, and the Director of the Division of Adoles-
                    cent and School Health. They generally agreed with the information


                    Page 30                           GAO/HRD-90403 AIDS Education   in Public Schools
Chapter 4
Conclusiona, Recommendations, and
Agency Comments




presented. The officials stated that HIV education should be locally
determined and consistent with parental values. These officials believe
that HIV education has expanded to other school districts since the time
of our data collection during the summer of 1989. CDC officials stated
that data on students’ knowledge, beliefs, and behaviors needed
improvement but that some data, even if not generalizable, could be use-
ful. After only 1 or 2 years of funding, the officials said, most school
districts in the nation have begun rapidly to provide some form of HIV
education, although much remains to be accomplished.




Page 31                             GAO/HRD-90-103 AIDS Education ln Public Schools
Appendix I

Excerpts From CDC’sGuidelinesfor
HIV Education


             Planning and Implementing                             Effective        School Health Education
             about AIDS
                  The Nation’s public and private schools have the capacity and responsibility                                   to
              help assure that young people understand                    the nature of the AIDS epidemic and the
              specific actions they can take to prevent                      HIV infection,        especially     during their
              adolescence       and young adulthood. The specific scope and content of AIDS education
              in schools should be locally determined                  and should be consistent with parental and
             community        values.
                  Because AIDS is a fatal disease and because educating                               young people about
              becoming       infected through         sexual contact can be controversial,                    school systems
              should obtain broad community                participation     to ensure that school health education
              policies and programs to prevent the spread of AIDS are locally determined                                 and are
              consistent with community             values.
                  The development          of school district policies on AIDS education can be an important
             first step in developing          an AIDS education program. In each community,                        representa-
             tives of the school board, parents, school administrators                         and faculty, school health
             services, local medical societies,              the local health department,                 students,     minority
             groups, religious organizations,             and other relevant organizations                can be involved in
             developing       policies for school health education to prevent the spread of AIDS. The
              process of policy development              can enable these representatives                 to resolve various
             perspectives       and opinions, to establish a commitment                    for implementing          and main-
             taining AIDS education             programs,      and to establish         standards       for AIDS education
             program       activities     and materials.      Many communities              already have school health
             councils that include representatives              from the aforementioned              groups. Such councils
             facilitate the development            of a broad base of community                  expertise and input, and
             they enhance the coordination              of various activities within the comprehensive                    school
             health program (6).
                  AIDS education          programs     should be developed             to address the needs and the
             developmental          levels of students and of school-age youth who do not attend school,
             and to address specific needs of minorities,                     persons for whom English is not the
             primary language, and persons with visual or hearing impairments                               or other learning
             disabilities.    Plans for addressing         students’ questions or concerns about AIDS at the
             early elementary          grades, as well as for providing            effective school health education
             about AIDS at each grade from late elementary/middle                                  school through          junior




                   Page 32                                                     GAO/HRD-90-103 AIDS Education in Public Schools
     Appendix I
     Excerpts From CDC’s Guidelines for
     HIV Education




 high/senior    high school, including      educational    materials    to be used, should be
 reviewed by representatives       of the school board, appropriate        school administrators,
teachers, and parents before being implemented.
     Education about AIDS may be most appropriate              and effective when carried out
within a more comprehensive           school health education       program that establishes        a
foundation     for understanding       the relationships    between      personal    behavior    and
 health (7-9). For example,       education     about AIDS may be more effective               when
students at appropriate       ages are more knowledgeable           about sexually transmitted
diseases, drug abuse, and community           health. It may also have greater impact when
they have opportunities      to develop such qualities as decision-making           and communi-
cation skills, resistance to persuasion,       and a sense of self-efficacy       and self-esteem.
However, education about AIDS should be provided as rapidly as possible, even if it
is taught initially as a separate subject.
    State departments      of education    and health should work together to help local
departments     of education and health throughout       the state collaboratively     accomplish
effective school health education about AIDS. Although all schools in a state should
provide effective education       about AIDS, priority should be given to areas with the
highest reported incidence of AIDS cases.

Preparation         of Education          Personnel
    A team of representatives          including     the local school board, parent-teachers
associations,     school administrators,        school physicians,       school nurses, teachers,
educational     support personnel, school counselors, and other relevant school person-
 nel should receive general training about a) the nature of the AIDS epidemic and
means of controlling     its spread, b) the role of the school in providing              education to
prevent transmission       of HIV, c) methods and materials                to accomplish     effective
programs of school health education about AIDS, and d) school policies for students
and staff who may be infected. In addition, a team of school personnel responsible for
teaching about AIDS should receive more specific training about AIDS education. All
school personnel, especially those who teach about AIDS, periodically                  should receive
continuing     education about AIDS to assure that they have the most current informa-
tion about means of controlling       the epidemic, including up-to-date information             about
the most effective health education          interventions    available.     State and local depart-
ments of education and health, as well as colleges of education,                  should assure that
such in-service training is made available to all schools in the state as soon as
possible and that continuing         in-service     and pre-service      training    is subsequently
provided.     The local school board should assure that release time is provided                      to
enable school personnel to receive such in-service training.

Programs Taught               by Qualified         Teachers
    In the elementary   grades, students generally have one regular classroom teacher.
In these grades, education about AIDS should be provided by the regular classroom
teacher because that person ideally should be trained and experienced               in child
development,    age-appropriate   teaching methods, child health, and elementary      health
education    methods and materials.        In addition, the elementary    teacher usually is
sensitive to normal variations     in child development     and aptitudes within a class. In
the secondary grades, students generally have a different teacher for each subject. In




     Page 33                                              GAO/HRD-90-103 AIDS Education in Public Schools
       Appendix I
       Excerpts From CDC’s Guidelinea for
       HIV Education




these grades, the secondary       school health education      teacher preferably      should
provide education about AIDS, because a qualified health education teacher will have
training and experience in adolescent development,       age-appropriate   teaching meth-
ods, adolescent health, and secondary school health educati’on methods and mate-
rials (including methods and materials       for teaching about such topics as human
sexuality, communicable    diseases, and drug abuse). In secondary schools that do not
have a qualified   health education    teacher, faculty with similar training       and good
rapport with students     should be trained specifically      to provide    effective    AIDS
education.


Purpose of Effective                 Education                 about AIDS
      The principal purpose of education   about AIDS is to prevent HIV infection.  The
content of AIDS education       should be developed   with the active involvement      of
parents and should address the broad range of behavior exhibited by young people.
Educational      programs should assure that young people acquire the knowledge     and
skills they will need to adopt and maintain types of behavior that virtually eliminate
their risk of becoming infected.
      School systems should make programs available that will enable and encourage
young people who have not engaged in sexual intercourse        and who have not used
illicit drugs to continue to -
   l   Abstain from     sexual intercourse               until they are ready to establish            a mutually
       monogamous       relationship  within             the context of marriage;
   l   Refrain from using or injecting              illicit   drugs.
      For young people who have engaged in sexual intercourse or who have injected
illicit drugs, school programs should enable and encourage them to-
   e Stop engaging in sexual intercourse  until they are ready to establish                           a mutually
     monogamous    relationship within the context of marriage;
   l   To stop using or injecting        illicit     drugs.
    Despite all efforts, some young people may remain unwilling          to adopt behavior
that would virtually     eliminate  their risk of becoming   infected. Therefore,    rchool
ryrtems,   in consultation     with parents and health officials,    should provide AIDS
education    programs     that address preventive    types of behavior      that should be
practiced by persona with an increased risk of acquiring HIV infection. There include:
   l   Avoiding sexual intercourse   with anyone who is known to be infected,                           who is at
       risk of being infected, or whose HIV infection status is not known;
   l   Using a latex condom         with spermicide              if they engage     in sexual    intercourse;
   l   Seeking treatment        if addicted        to illicit drugs;
   l   Not sharing    needles     or other injection             equipment;
   l   Seeking   HIV counseling       and testing             if HIV infection   is suspected.
   State and local education and health agencies should work together to assess the
prevalence of these types of risk behavior, and their determinants, over time.




       Page 34                                                         GAO/HRD-90-103 AIDS Education in Public Schools
     Appendix I
     Excmpta F’rom WC’s Guidelines for
     HIV Education




Curriculum        Time and Resources
    Schools should allocate sufficient     personnel  time and resources to assure that
policies and programs are developed and implemented             with appropriate   community
involvement,   curricula are well-planned   and sequential, teachers are well-trained,     and
up-to-date teaching methods and materials about AIDS are available. In addition, it is
crucial that sufficient classroom time be provided at each grade level to assure that
students acquire essential knowledge      appropriate   forthatgrade     level, and have time
to ask questions and discuss issues raised by the information          presented.


Program Assessment
   The criteria recommended    in the foregoing     “Guidelines for Effective School Health
Education To Prevent the Spread of AIDS” are summarized               in the following    nine
assessment criteria. Local school boards and administrators        can assess the extent to
which their programs are consistent with these guidelines        by determining     the extent
to which their programs meet each point shown below. Personnel in state depart-
ments of education and health also can use these criteria to monitor the extent to
which schools in the state are providing     effective health education about AIDS.
   1. To what extent are parents, teachers, students, and appropriate                community
       representatives      involved in developing,      implementing,     and assessing     AIDS
      education policies and programs?
   2. To what extent is the program            included     as an important     pan of a more
      comprehensive        school health education program?
   3. To what extent is the program             taught by regular classroom         teachers    in
      elementary      grades and by qualified health education teachers or other similarly
      trained personnel in secondary        grades?
   4. To what extent is the program           designed to help students acquire essential
      knowledge      to prevent HIV infection at each appropriate        grade?
   5. To what extent does the program describe the benefits of abstinence for young
      people and mutually monogamous            relationships   within the context of marriage
      for adults?
   6. To what extent is the program designed to help teenage students avoid specific
      types of behavior that increase the risk of becoming infected with HIV?
   7. To what extent is adequate training about AIDS provided for school adminis-
      trators, teachers, nurses, and counselors-especially             those who teach about
      AIDS?
  8. To what extent are sufficient program development             time, ClaSSrOOm time, and
     educational  materials provided for education about           AIDS?
  g. To what extent are the processes        and outcomes           of AIDS education   being
     monitored   and periodically  assessed?




    Page 36                                           GAO/I-IRD9O-103 AIDS Education in Public Schools
Amendix II

Estimatesand SamplingErrors for Selected                                                                                 ’
GAO Interview Responses

                                                                                                   Sampling error”
                                                                        Estimated school            (+ percentage
              Variable                                                  districts (percent)                 points)
              School districts requiring HIV education                                     66                        6
              School districts not requiring HIV education                                 27                        6
              School districts with grades 7-12 requiring HIV
                education at every grade level                                              5                        4
              School districts requiring HIV education in health
                courses                                                                    79                        6
              School districts with HIV teachers obtaining in-
                service trainino                                                           88                        5
              HIV teachers receiving in-service training                                   83                       11
              School districts reporting the number of HIV
                teachers trained is:
                   More than enough                                                         9                        5
                   About what is needed                                                    64                        8
                   Less than is needed                                                     25                        7
              School districts reporting:
                                                                                           54                        8
              -- They want to do more HIV in-service training
                   The amount of in-service already received is
                     about right                                                           43                        8
              ‘Sampling errors are computed at the 95-percent confidence level, i.e., we are 95.percent confident that
              the true proportion of school districts is between the ranges specified by the estimate.




              Page 36                                        GAO/HRD-90-103 AIDS Education in Public Schools
Ppt3

%&     SuggestedKBB Questionsfor Students



             AIDS is a very serious health problem in our Nation.     Health officials  are
             trying   to find the best ways to teach people about AIDS and the human
             immunodeficiency    virua (HIV), that causea AIDS. This survey haa been
             developed so you can tell us what yak know and how YQY feel about AIDS/HIV.
             The information   you give will be used to develop better AIDS/HIV education
             programs for young people like yourself.


             DO NOT write your name on this survey p,~ the answer sheet. The answers you
             give will be kept private.   No one will know what you write.  Answer the
             questions based on what you really know, feel, or do.


             Completing the survey is voluntary.            Whether or not you answer the questions
             will not affect your grade in this          class.


             The questions    in Part 1 that ask about your background will only be used to
             describe   the types of students completing   this survey. The information will
             not be used to find out your name. No names will ever be reported.

             Place all your answer on the answer sheet.   Fill  in the circles     completely.
             Make aure to answer every question.   When you are finished,    follow the
             instructions  of the person giving you the survey, and place your answer sheet
             in the box or envelope provided for you.



              You need to understand      two related    words used in this         survey:    AID5 and HIV.

                   0        AIDS stands   for acquired     immunodeficiency        syndrome.

                   0        AIDS is caused by the virus,       HIV.

                   0        HIV stands for human immunodeficiency         virus.       HIV is the virus
                            that causes AIDS.




                                       THANK YOU VERY MUCHFOR YOUR HELP.




                       Page 37                                   GAO/HRD90-103 AIDS Education in Public Schools
                                              PART 1


Read each quertion      carefully.  Fill      in the circle    on your answer sheet      that
matches the letter      of your answer.
 1.   What grade    are you in?

      a. 9TH        b. 1OTH         c. 1lTH       d. 12TH        e. UNGRADEDOR OTHER

 2.   What    is your sex?

      a. FEMALE         b. BALE

 3.   How old are you?

      a.     12 YEARS OLD OR YOUNGER
      b.     13-14 YEARS OLD
      c.     15-16 YEARS OLD
      d.     17-18 YEARS OLD
      e.     19 YEARS OLD OR OLDER


 4.   Are you Hispanic       or Latino?

      a. YES        b. NO


 5.   What la your race?

      a.     BLACK
      b.     WHITE
      c.     ABERICAN INDIAN OR ALASKAN NATIVE
      d.     ASIAN OR PACIFIC ISLANDER
      e.     OTHER


                                              PART 2


Read each question      carefully.  Fill      in the circle    on your answer sheet      that
matches the letter      of your answer.


 6.   Should students     your age be taught      about AIDS/HIV    infection    in
      school?

      a. YES       b. NO         c. NOT SURE


 7.   Have you been taught       about AIDS/HIV    infection   in school?

      a. YES       b. NO         c. NOT SURE




       Page 38                                      GAO/I%RMO-103     AILIS Education   in Public Schools
      Appendix III
      CM% Suggested KBB Questions for Students




 8.   Should a student      with    AIDS/HIV     infection       be allowed     to go to your
      school?
      a.   YES    b. NO            c. NOT SURE


 9.   Would you be willing         to be in the same class           with     a student     with
      AIDS/HIV infection?

      a. YES      b. NO            c. NOT SURE


10.   Do you know where to get good information                   about AIDS/HIV         infection?

      a. YES      b. NO            c. NOT SURE


11.   Do you know where to get tested                to see if   you are infected          with    the
      AIDS virus (HIV)?

      a. YES      b.   NO          c. NOT SURE


12.   Do you know how to keep from getting                the AIDS virus        (HIV)?
      a. YES      b.   NO          c. NOT SURE


13.   Have you ever talked         about AIDS/HIV        infection    with     a friend?

      a. YES      b. NO


14.   Have,you ever talked about AIDS/HIV                infection    with     your parents        or
      other adults in your family?

      a. YES      b. NO




15.   Can a person get AIDS/HIV         infection        from holding        hands with     someone?

      a. YES      b. NO            c. NOT SURE


16.   Can a person get AIDS/HIV         infect       ion from sharing       needles   used to
      inject (shoot up) drugs?

      a. YES      b. NO            c. NOT SURE




                                                 3




      Page 39                                            GAO/HRD-90-103 AIDS Education in Public Schools
       Appendix III
       CDC’e Suggested KBB Questions for Students




17.   Can a person get AIDS/HIV      infection   from    being     bitten       by moa9uitoe
      or other insecte?

      a. YES        b. NO       c. HOT SURE

lg.   Can a peraon get AIDS/HIV     infection    from donating         blood?

      a. YES        b. NO      c. NOT SURE


19.   Can a person get AIDS/HIV     infection    from having        a blood        test?

      a. YES        b.   NO    c. NOT SURE

20.   Can a person get AIDS/HIV     infection    from using        public       toilets?

      a. YES        b. NO      c. NOT SURE


21.   Can a person get AIDS/HIV     infection    from having        sexual       intercourse
      without a condom (rubber)?

      a. YES        b. NO      c. NOT SURE


22.   Can    a person get AIDS/HIV infection   from being          in the same class
      with    a student who has AIDS/HIV infection?

      a. YES        b. NO      c. NOT SURE




23.   Can you tell if people     are infected    with    the AIDS virus           (HIV)    just
      by looking at them?

      a. YES        b. NO      c. NOT SURE


24.   Can a person who has the AIDS virus        (HIV)    infect     someone else during
      sexual intercourse?

      a. YES         b. NO      c. NOT SURE


25.   Can a pregnant woman who has the AIDS virus           (HIV)      infect      her unborn
      baby with the virus?

      a. YES        b. NO      c. NOT SURE




                                           4




       Page 40                                    GAO/HRD-90-103 AIDS Mucation                    in Public Schools
    .
.
              Appendix III
              CDC’s Suggested KBB Questlone for Students




        26.   Is there        a cure for AIDS/HIV     infection?
              a. YES            b. A0       c. HOT SURE

        27.   Ia it    true     that   only homosexual       (gay)    men can get AIDS/HIV      infection?

              a. YES           b. NO        c. NOT SURE




        28.   Can people seduce their chances of becoming infected with the AIDS
              virus (HIV) by & having any kind of sexual intercourse    (being
              abstinent)?
              a. YES           b. NO        c. NOT SURE

        29.   Can people ~..&qg their chances of becoming infected                      with the AIDS
              virus (HIV) by using condoms (rubbers) during sexual                      intercourse?

              a. YES           b. NO        c. NOT SURE


        30.   Can people reduce their chances of becoming infected with the AIDS
              virus (HIV) by DQ& having any kind of sexual intercourse with a
              person who has injected  (shot up) drugs?

              a. YES           b. NO        c. NOT SURE


        31.   Can people reduce their chances of becoming                    infected   with   the AIDS
              virus (HIV) by taking birth control pills?

              a. YES           b. NO        c. NOT SURE


                                                      PART 3

        Read each question carefully.    Fill in the circle                   on your answer sheet
        that matches the letter   of you answer.


        32.   Have you w     injected         (shot   up) cocaine,        heroin,   or other    illegal
              drugs into your body?

              a. YES           b. NO




                                                         5




              Page 41                                                GAO/HRD-90-103 AIDS Education in Public Schools
                                                                                                                   ,


           CDC’r Suggested KBB Queetions for Students




33.   wthct                 YU,        have you injected (shot            up) cocaine,      heroin,       or
      other      illegal          drugs into your body?
      a. YES               b. NO

34.   Have you u                  shared needles      used to inject        (shoot     up),any     drugs?
      a. YES               b. NO


35.   ID.the last          gear,      have you shared needles             used to inject         (shoot    up)
      any drugs?

      a. YES               b. NO




36.   With how many people                 have you had any kind           of sexual     intercourse           u
      -life?
      a. 0           b. 1             C.   2       d. 3        e. 4 OR MORE


37.   With how many people                 have you had any kind           of sexual     intercourse           b
      the?
      a. 0           b. 1             C.   2       d. 3        e.   4   OR MORE


38.   How old were you the first                   time you had any kind             of sexual
      intercourse?

      a.      I HAVE NEVER HAD ANY KIND OF SEXUAL INTERCOURSE
      b.      12 YEARS OLD OR YOUNGER
      C.      13-14 YEARS OLD
      d.      15-16 YEARS OLD
      e.      17-M YEARS OLD

39.   When you have any kind                   of sexual   intercourse,       how often      is a condom
      (rubber) used?

      a.      I HAVE NZVER HAD ANY KIND OF SEXUAL INTERCOURSE
      b.      ALWAYS
      C.      SOmETIMES
      d.      RARELY
      e.      NEVER




                      THANK YOU VERY MUCHFOR YOUR TIME AND HELP.


                                                       6
                                                                                                                       J




       Page 42                                                 GAO/HRIMO-103 AIDS Education in Public Schools
ApMndix   IV

Topics CoveredDuring h-service Training by
13 CDGF’undedDistricts


                                                             Length of coverage (percentage of district!W
                                                              Mo; $3; 15 min. or                      Don’t
               Training topics                                          .      less Not at all        know
               How HIV is transmitted                                     100       0          0           0
               Behaviors that put a person at risk for
                  getting HIV                                             100       0          0           0
               Unprotected heterosexual intercourse
                  as a riskv behavior                                     85       15          0           0
               Unprotected homosexual intercourse as
                  a risky behavior                                        85       15          0           0
               Multiple sex partners as a risky
                  behavior                                                69      31           0           0
               IV drug use as a risky behavior                            85      15           0           0
               Importance of using condoms to
                  prevent the spread of HIV                               92        8          0           0
               How blood and other bodily fluids
                  should be handled for HIV infection
                  control                                                 85       8           8           0
               How to handle embarrassing questions
                  from students                                           85       15          0           0
               How to raise students’ self-esteem                         85       15          0           0
               How to teach students to resist peer
                  pressure                                                92       8           0           0
               How to communicate sensitive subjects
                  to students                                             92       8           0           0
               Legal and other policies related to AIDS
                  that school districts should follow                     69      31           0           0
               Resources available in the community
                  to deal with HIV issues                                 85       15          0           0
               ‘Percentages may total to more than 100 due to rounding.




               Page 43                                       GAO/HRD!tO-103 AIDS Education in Public Schools
Topics CoveredDuring In-ServiceTraining by ’
SchoolDistricts Nationwide

                                                            Length of coverage (percentage of districts)‘*b
                                                              More than 15 min. or                    Don’t
               Training topics                                   15 min.       less Not at all        know
               How HIV is transmitted                                 85          8         0               7
               Behaviors that put a person at risk for
                 getting HIV                                            76            16       0           7
               Unprotected heterosexual intercourse
                 as a risky behavior                                    45            52       2            1
               Unprotected homosexual intercourse as
                 a risky behavior                                       38            59       2           2
               Multiple sex partners as a risky
                 behavior                                               39            59        1          2
               IV drug use as a risky behavior                          61            38        1          0
               importance of using condoms to
                   urevent the spread of HIV                            46            52       2           0
               How blood and other bodily fluids
                  should be handled for HIV infection
                  control                                               55            35        1          9
               How to handle embarrassing questions
                 from students                                          55            30       6           9
               How to raise students’ self-esteem                       46            33      10          11
               How to teach students to resist peer
                  pressure                                              60            27       6           7
               How to communicate sensitive subjects
                 to students                                            53            32       6          10
               Le al and other policies related to AIDS
                  t\ at school districts should follow                  40            43       7          10
               Resources available in the community
                 to deal with HIV issues                                42            46       3          10
               8Percentages may not total-100 due to rounding.
               bSampling errors for these percentages do not exceed 8 percentage points.




               Page 44                                       GAO/fIRJMO-103 AIDS Education in Public Schools
            ;>;:Contributors to This Report


                        Janet L. Shikles, Director, Health Financing and Policy Issues,
Human Resources            (202)276-646 1
Division,               Michael Gutowski, Assistant Director
Washin&on, DC.          Cindy Bascetta, Assistant Director
                        Cheryl Oros, Assignment Manager
                        Joanne Frankel, Social Science Analyst
                        Virginia T. Douglas, Reports Analyst


Atlanta Regional         Martin G. Landry, Evaluator-in-Charge
Office                   Eva 2. Margolies, Site Senior
                         Lisa M. Warde, Evaluator




(lOf3702)                Page 45                          GAO/HRDW103   AID5 Education in Public Schools
li
     ‘l’t*lt~ptlollt~ 202-275-6241
i
     ‘lb first five wpichs of each report, arty frw. Additional   copiw   art’
t
     11;2.00twdl.
                                                  “3   il,
                                     *                 h
-.-   1-----“-1   .-.-   111*--1-~       m-.--L        ”